Provider Demographics
NPI:1699469965
Name:ROMAN, MARC
Entity type:Individual
Prefix:
First Name:MARC
Middle Name:
Last Name:ROMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 VALHALLA RD
Mailing Address - Street 2:
Mailing Address - City:CARMEL
Mailing Address - State:NY
Mailing Address - Zip Code:10512-6630
Mailing Address - Country:US
Mailing Address - Phone:184-580-3988
Mailing Address - Fax:
Practice Address - Street 1:100 WOODS ROAD
Practice Address - Street 2:
Practice Address - City:VALHALLA
Practice Address - State:NY
Practice Address - Zip Code:10595
Practice Address - Country:US
Practice Address - Phone:914-493-7000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-08
Last Update Date:2023-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY030841363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Single Specialty